When suctioning to remove secretions from an artificial airway, the nurse should limit the suction time to:
a. 1 minute.
b. 5 seconds.
c. 10 seconds.
d. 15 seconds.
B
The nurse should limit suctioning to no more than 5 seconds.
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Which critical thinking skill helps the nurse see relationships among the data?
a. Validation b. Clustering related cues c. Identifying gaps in data d. Distinguishing relevant from irrelevant
When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications of shock. How can the nurse best achieve this goal?
A) Provide a detailed diagnosis and plan of care in order to promote the patient's and family's coping. B) Keep the physician updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. C) Monitor for significant changes and evaluate patient outcomes on a scheduled basis focusing on blood pressure and skin temperature. D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.
As the result of a brain tumor, a patient is having trouble with balance. The patient's significant other is concerned and asks the nurse how a tumor could affect the patient's balance
The nurse explains that the tumor is growing in the part of the brain that is responsible for balance. The significant other asks, "Which part of the brain controls balance?" The nurse's response would be which of the following? a. Pons b. Cerebrum c. Cerebellum d. Hypothalamus
A victim of spousal abuse comes to the emergency department for treatment of a broken nose. She appears hypervigilant and anxious and admits to sleep disturbance when the nurse questions the dark circles under her eyes
She reluctantly tells the nurse the abuse usually occurs when the husband has been drinking, although she concedes he is always jealous and controlling. She is a stay-at-home mother of two preschool children. The family has lived in this town for 1 month. The patient states she has fleetingly considered suicide but must stay alive to care for her children and work her way out of the abusive relationship. She denies having had the desire to kill her husband and has no history of violence. The nurse should document in the medical record that: (Select all that apply.) a. signs of high anxiety and chronic stress are present. b. the patient relies on the perpetrator for basic needs. c. the patient is isolated from individual and community support. d. suicide risk is high and merits inpatient admission. e. the immediate risk of revenge homicide is low. f. a safety plan should be constructed before discharge.